Speaker Name/Credentials

Estimated Time of Talk

CME Accreditation

Description

This webinar will cover how dietary fat influences the microbiome and how in turn this can have effects on immune and metabolic function.

Learning Objectives

Learn how fat in the diet influences composition of the microbiome

Understand the health benefits of microbiome fermentation

Review dietary components that can shift the microbiome and influence health

Disclosures

None

This enduring material activity, Effect of Dietary Lipids on the Gut Microbiome: What Do We Know?, has been reviewed and is acceptable for up to 0.75 prescribed credits by the American Academy of Family Physicians. Term of approval begins October 3, 2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosures

This enduring material activity, Metabolic Basis of CVD Prevention, has been reviewed and is acceptable for up to 1.00 prescribed credits by the American Academy of Family Physicians. Term of approval begins October 3, 2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosures

This enduring material activity, Identifying Subclinical Cardiovascular Disease, has been reviewed and is acceptable for up to 1.00 prescribed credits by the American Academy of Family Physicians. Term of approval begins October 3, 2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Estimated Time of Talk

CME Accreditation

Description

This webinar will cover clinical implications and therapeutic approaches to patients who are poor responders to aspirin therapy.

Learning Objectives

Learn how aspirin therapy reduces cardiovascular events.

Review how 11-dhTXB2 levels can indicate aspirin effectiveness.

Therapeutic considerations and additional testing for those who are poor responders to aspirin therapy.

Conflicts of Interest

Speaker- Amgen, Aralez, Cleveland HeartLab

This enduring material activity, Aspirin Effectiveness and its Influence on Cardiovascular Risk, has been reviewed and is acceptable for up to 1.00 prescribed credits by the American Academy of Family Physicians. Term of approval begins May 1, 2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Conflicts of Interest

This enduring material activity, Reducing Cardiovascular Risk in the Patient with Elevated Triglycerides, has been reviewed and is acceptable for up to 1.00 prescribed credits by the American Academy of Family Physicians. Term of approval begins May 1, 2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Conflicts of Interest

This enduring material activity, Cardiovascular Health in Menopausal Women: Understanding the Critical Triad of Aging, Hormones, and Inflammation, has been reviewed and is acceptable for up to 1.00 Prescribed credits by the American Academy of Family Physicians. Term of approval begins May 1, 2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Conflicts of Interest

Remember when we used to tell patients that high-density lipoprotein cholesterol (HDL-C) was “healthy” of the “highly desirable lipoprotein”? Well, a number of research studies in recent years have caused cardiovascular and lipid experts to say that the information obtained about HDL via epidemiology led us in the wrong direction.

One pharmaceutical company lost almost a billion dollars when it’s trial of a cholesterol ester transfer protein (CETP) inhibitor more than doubled HDL-C but patients in the treatment group had a higher death rate, so the trial was halted early as raising HDL-C failed to provide benefit. Other clinical trials that used niacin, which significantly increases HDL-C but doesn’t significantly increase HDL particle number, failed to improve cardiovascular clinical outcomes. This in turn led authors of the American College of Cardiology (ACC) not to recommend niacin in the March 2016 clinical guidelines regarding the role of non-statin therapies in the management of cardiovascular risk.

A more recent study by Sharif and colleagues published in the May issue of Diabetes Care sought to find out if low HDL-C was a risk factor for cardiovascular disease and mortality in subjects with type 2 diabetes mellitus. They also wanted to find out if low HDL-C would remain a residual risk factor in those on intensive lipid-lowering therapy and/or if LDL-C goals were met.

Data was obtained from a cohort (n=1829) of subjects with diabetes enrolled in the Second Manifestations of ARTerial Disease (SMART) trial. LDL-C levels were stratified into three groups: <77 mg/dL, 77-97 mg/dL, and >97 mg/dL and the intensity of their lipid-lowering therapy. Adjustments were made relating to confounding variables such as BMI, gender, age, triglycerides, LDL-C, HbA1c, glucose, estimated glomerular filtration rate, alcohol, and smoking. During the (median) 7 years of follow-up, there were 335 new cardiovascular events and 385 deaths. The investigators found no relationship between HDL-C levels and cardiovascular events. In fact, in their conclusion they stated that they unexpectedly found that subjects with Diabetes and LDL-C levels <77 mg/dL and higher HDL-C at baseline had an increased risk of cardiovascular events and all-cause mortality.

So… gone are the days when we can simply say that HDL is “good”. Experts continue to marvel at the recent discoveries related to the complexity of the proteomics and lipidomics of HDL cholesterol. In order to prevent events, we need to move beyond HDL-C measurements. Research is currently underway to help us understand how HDL functions and how we can better identify those who are at a higher cardiovascular risk based on HDL functionality rather than on the amount of cholesterol found in the HDL particle.

Be able to prioritize and personalize the most important nutritional, nutraceutical supplements and life style treatments for hypertension

Conflicts of Interest

Dr. Houston is an independent contractor/consultant for Biotics Research, Spectracell, Designs for Health, Thorne, Vibrant America Labs, Cleveland HeartLab and AC Grace and he is on the review panel/board for Designs for Health, Thorne, Boston Heart Lab, Itamar and receives grants from private industry from Biotics, Thorne and Neogenis.

Although psychological stress has been linked to cardiovascular disease risk for years, our understanding of the connection continues to grow. Dr. Ahmad Tawakol and colleagues at Massachusetts General Hospital in Boston presented information at the 2016 American College of Cardiology sessions from a study they did in 293 patients who had PET/CT scans between 2005 and 2008. Subjects who had evidence of cancer, established cardiovascular disease or who were younger than age 30 were excluded. This first-of-kind study revealed a relationship between amygdala activity in the brain, associated with stress and fear, and arterial inflammation. In addition to objective measurements of brain activity, the scans allowed for measurements in arteries and bone marrow. Over approximately a 5 year study period and after correction for cardiovascular risk factors based on Framingham Risk and age and gender, investigators found that 35% of the subjects in the high amygdala activity group had a cardiovascular event, whereas only 5% in the low amygdala activity group suffered such. Dr. Tawakol proposed that perhaps the activation of the amygdala, bone marrow, and arterial inflammation together contribute to a mechanism that may lead to cardiovascular events. In his concluding remarks, Dr. Tawakol stated that the risk of heart disease linked to stress is on par with other major risk factors. Further studies are needed, but perhaps those of us interested in the prevention of cardiovascular events might want to evaluate inflammatory biomarkers in our patients who are under stress in an effort to uncover hidden risk and/or subclinical cardiovascular disease.

A recent prospective study based on data from 115,541 women free of known cardiovascular disease (CVD) who were enrolled in the Nurses’ Health Study II was published in the British Medical Journal. The researchers sought to determine if there was a link between migraine headaches and incident CVD and CVD mortality in women. Of the subjects enrolled, 15.2% (n=17,531) had physician diagnosed migraine headaches. Subjects with diagnosed migraines ranged in age from 25-42 years and were followed for over 20 years with a cumulative follow-up rate >90%. Despite adjustment for potential confounders, migraine headaches were strongly associated with incident stroke (hazard ratio 1.62, 1.37 – 1.92), coronary revascularization procedures/angina (1.73, 1.20 – 2.32), myocardial infarction (1.39, 1.18 to 1.64) and CVD mortality (1.37, 1.02 – 2.32). These associations held across various subgroups of women by age (<50/≥50 years) and whether or not they had hypertension or were on oral contraceptives or post-menopausal hormone replacement therapy.

The investigators concluded that there was a strong consistent link between CVD events, including CVD mortality, and migraine headaches and recommended that women with migraine headaches be more aggressively evaluated for vascular risk (and subclinical disease.)

The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Guidelines, based solely on a limited number of randomized controlled clinical trials with statin therapies, recommended reductions of LDL-cholesterol (LDL-C) by >50% or 30-50% for various populations based on trial data and clinical outcomes. The authors of the document stated they were “not for or against targets” ….but not including guidelines with cholesterol targets or goals led to confusion and controversy amongst experts, clinicians, and patients. Read more Are Lipid Targets Back? ›

Dr. David Jenkins and colleagues have now shown that a variation of the Portfolio Diet (viscous fiber, soy protein, plant sterols, and almonds) proven to lower LDL-C and hsCRP in 2003, also lowers blood pressure (BP). Previous studies had alluded to this potential benefit, so Jenkins et al. looked at pooled data from a study that compared a DASH-type diet to intensive application of the portfolio diet in 241 hyperlipidemic subjects. Read more New Study Shows Portfolio Diet Lowers BP (in addition to LDL-C & hsCRP) ›

Since statins are often discontinued due to tolerability problems, a study of dyslipidemic patients (n=100) post percutaneous coronary intervention by Marazzi and colleagues published in the Journal of the American College of Cardiology sought to determine the value of a combination of nutraceuticals (policosanol, folic acid, red yeast rice, berberine, astaxanthin and coenzyme Q10) called Armolipid Plus, with or without ezetimibe in getting these patients’ low-density lipoprotein cholesterol (LDL-C) <100 mg/dL. Read more Recent Study Shows Nutraceuticals Improve Abnormal LDL-C ›

Gut microbes live symbiotically within the human digestive tract and play important roles in host defense, immunity, and nutrient processing and absorption. This diverse community is unique to each person and influenced by both acute and chronic dietary exposures to various food sources. Nutrients such as phosphatidylcholine (also known as lecithin), choline, and L-carnitine are abundant in animal-derived products such as red meat, egg yolk and full-fat dairy products. When consumed, these nutrients are processed by gut bacteria resulting in the release of various metabolites including TMA (trimethylamine) into the blood. TMA is then transported to the liver where it is converted into TMAO (trimethylamine N-oxide) which has been shown to regulate various physiological processes involved in the development of atherosclerosis.

According to recently published research in the journal Circulation, Shikany and colleagues sought to find out if the risk of acute coronary heart disease (CHD) was associated with dietary patterns. The Reasons for Geographic and Racial Differences in Stroke (REGARDS) trial data base (n=17,418) was used. Subjects were enrolled in this national, population-based trial that was conducted in both white and black adults between 2003 and 2007. Read more New Research Reveals the Hazards of a Southern Dietary Pattern ›

Cardiologists are acknowledging the need to better refine cardiovascular risk assessment in women. According to information recently published in the Journal of the American College of Cardiology, women are more likely to have nonobstructive coronary artery disease (CAD) than men. Since nonobstructive CAD, characterized by soft plaque, is known to precede plaque rupture that can lead to devastating cardiovascular events, there is reason for practitioners to pay attention to these gender differences. Read more Nonobstructive CAD, Women, and Prevention of Cardiovascular Events ›

According to the Expert Opinion of Peter Libby, MD, internationally renowned for his work in cardiovascular disease research and just published in the journal Cardiology, “In an era of precision medicine, the ability to target either LDL or inflammation, or both, depending on an individual’s biomarker profile, should allow us to personalize therapy in the secondary prevention of coronary heart disease.” Read more Is Now the Time to Target Both LDL and Inflammation? ›

According to a study published recently in the journal Atherosclerosis, Lipoprotein (a) is a risk factor for ischemic stroke. The meta-analysis conducted by Alexander Nave, et. al., reviewed data from 20 articles (studies that did not differentiate between hemorrhagic and ischemic stroke were excluded) that included 90,904 subjects and 5029 stroke events. Read more Analysis Reveals Lipoprotein “little a” [Lp(a)] Independently Predicts Stroke ›

It is well known that those who have just had a heart attack are at highest risk for future events. The “culprit” lesion for the event, may not, however be the only one lurking in the near term, just the only one exposed at the moment. A recent study published in the Journal of the American Heart Association was designed to investigate systemic atherosclerotic acceleration in relation to the acute inflammatory response surrounding acute myocardial infarction (MI). Read more Study Shows Increased Systemic Inflammation Linked to Risk of Recurrent Heart Attack ›

Speaker Name / Credentials

Estimated time of Talk

45 minutes

Description

This webinar will review the National Lipid Association recommendations for dietary modifications intended to lower levels of atherogenic cholesterol [low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C)], with an emphasis on dietary adjuncts to a diet low in saturated fats, trans fats, and cholesterol.

Learning Objectives

Review lipids and lipoproteins and their relationship to atherosclerotic cardiovascular disease (ASCVD) risk.

Speaker Name / Credentials

Estimated time of Talk

45 minutes

Description

This webinar will cover nutritional and lifestyle approaches to insulin resistance and cardiometabolic disease.

Learning Objectives

Participants should be able to recognize the physiologic connections between environment (nutritional and lifestyle choices) and gene expression as an influence upon phenotypic expression of insulin resistance and cardiometabolic disease.

Participants should be able to recommend nutritional and lifestyle medicine approaches in a personalized, evidence-based approach for insulin resistance and cardiometabolic disease.

Participants should be able to understand use of phytonutrients, medical foods, and lifestyle change programs as nutritional support for relevant chronic diseases.

What you “need to know” about PCSK9 Inhibitors

Several new drugs that significantly reduce low density lipoprotein (LDL) cholesterol levels have recently been recommended by experts for approval by the Federal Drug Administration (FDA). Many are optimistic about the approval of alirocumab (suggested trade name Praluent) on July 24th and evolocumab (suggested trade name Repatha) on August 27th. Read more Are Revolutionary New Drugs on the Horizon to Reduce CV Risks? ›

A post-hoc analysis of data from two large studies that enrolled subjects post-acute coronary syndrome (ACS) was recently published in the Journal of the American College of Cardiology. Investigators sought to find out if there was a relationship between baseline fasting triglyceride (TG) levels, prior to randomization, and major cardiovascular events. Read more Fasting Triglycerides Point to Risk After Acute Coronary Syndrome ›

MPO is a white blood cell-derived inflammatory enzyme that measures disease activity from the luminal aspect of the arterial wall. Briefly, when the artery wall is damaged, or inflamed, MPO is released by invading white blood cells where it accumulates. MPO mediates the vascular inflammation that propagates plaque formation and activates protease cascades that are linked to plaque vulnerability. White blood cell activation in the bloodstream, in response to luminal injury of the artery wall including fissures, erosions or a degrading collagen cap, leads to MPO release in the bloodstream. This combination of detrimental effects demonstrates that MPO is actively involved in the progression of atherosclerosis.

F2-IsoPs, prostaglandin-like compounds formed from the free radical-mediated oxidation of arachidonic acid, are the ‘gold standard’ for measuring oxidative stress in the body. F2-IsoPs also have potent biological effects associated with inflammation and therefore may mediate chronic disease initiation and progression. Additionally, F2-IsoPs may also act as potent vasoconstrictors via thromboxane formation in the endothelium, and promote platelet activation resulting in thrombus formation.

OxLDL measures protein damage due to the oxidative modification of the ApoB subunit on LDL cholesterol. The oxidation of LDL cholesterol is one of the first steps in the development of atherosclerosis. Briefly, LDL-C enters the artery wall where it becomes oxidized. OxLDL is then recognized by scavenger receptors on the macrophages which engulf OxLDL, resulting in foam cell formation, vascular inflammation and the initiation of atherosclerosis.

Microalbumin is the quantification of small amounts of albumin, a serum protein, in urine that can be used to identify microvascular endothelial dysfunction. The presence of small amounts of albumin in the urine may suggest the presence of systemic endothelial dysfunction – an early indicator of heart disease. This test is more sensitive than a standard dipstick test routinely performed in an office setting.

The hsCRP test is a highly sensitive quantification of CRP, an acute-phase protein released into the blood by the liver during inflammation, which has been associated with the presence of heart disease.

Lp-PLA2, or lipoprotein-associated phospholipase-A2, measures disease activity within the artery wall below the collagen or calcified cap due to the activation of macrophages. Lp-PLA2 is not an acute phase reactant. When disease is active in the artery, increased levels of Lp-PLA2 are produced by macrophages and foam cells within the intima of the artery. Lp-PLA2 also interacts with oxidized LDL, which increases inflammation and enhances a proatherogenic state, as well as plaque vulnerability. Research suggests that it plays a direct role in the atherosclerotic disease process.

Coenzyme Q10 (CoQ10) is a fat-soluble, vitamin-like substance present in most cells, primarily in mitochondria. CoQ10 has two major roles within the human body: it participates in aerobic cellular respiration generating energy (i.e., ATP) and is a powerful antioxidant. CoQ10 exists as two forms in the body: ubiquinone and ubiquinol (the active form of CoQ10, which is made from ubiquinone).

AspirinWorks® is an enzyme-linked immunoassay (ELISA) to determine levels of 11-dehydrothromboxane B2 (11-dhTXB2) in urine which aids in the quantitative detection of aspirin effect in apparently healthy individuals post-ingestion.

MTHFR (5,10-methylenetetrahydrofolate reductase) is an enzyme involved in the metabolism of folate. MTHFR catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate, the major circulating form of folate. In turn, 5-methyltetrahydrofolate is involved in the conversion of homocysteine to methionine. MTHFR has an important role in maintaining folate and methionine levels, as well as helping to keep circulating homocysteine levels low. MTHFR is also involved in the methylation pathway, which has multiple, wide-ranging roles in the body, including regulation of gene expression and enzymatic activities.

CYP2C19 is a member of the cytochrome P450 family of enzymes involved in the metabolism and bioactivation of drugs. In particular, CYP2C19 is integral for the generation of the active form of clopidogrel (Plavix®), which is prescribed in a prodrug form. This prodrug is converted by CYP2C19 to the active form in the liver. Several variants of CYP2C19 have been identified which have an impact on its ability to metabolize drugs. The main CYP2C19 alleles include the non-functional alleles *2 and *3, as well as the hyperactive *17 allele.

ApoE is an apolipoprotein found in blood that, in association with lipids, forms lipoproteins including very low-density lipoproteins (VLDL). ApoE plays multiple roles in the regulation of lipid and lipoprotein levels in the blood. ApoE serves as a ligand for members of the low-density lipoprotein (LDL) receptor family, and is involved in the removal of lipoproteins from the circulation for excretion in the liver. ApoE is also involved in the formation of chylomicrons and VLDL, and affects the activity of other proteins and enzymes that are involved in lipid metabolism, such as hepatic lipase and lipoprotein lipase.

Adiponectin is an abundant hormone released by adipocytes (or fat cells), commonly referred to as an adipokine. Adiponectin plays a large metabolic role in the body, participating in the regulation of glucose levels, insulin sensitivity and lipid catabolism. Adiponectin also helps support proper endothelial functioning and has multiple anti-inflammatory properties, including inhibiting the transformation of macrophages to foam cells, one of the first steps of atherosclerosis.

Omega-3 and omega-6 fatty acids are polyunsaturated long chain fatty acids (PUFA) required by the body for proper functioning, normal growth and the formation of neural synapses and cellular membranes. Omega-3 and -6 fatty acids are considered “essential” and obtained primarily from dietary sources.

HDL cholesterol, like LDL cholesterol, can be divided into several subfractions, based on density, size and protein composition. The HDL2 subfraction (HDL2a, HDL2b) consists of larger, more buoyant particles while particles in the HDL3 subfraction (HDL3a, HDL3b, HDL3c) are smaller and denser. The largest and most buoyant HDL particle is HDL2b.

Vitamin D is a fat-soluble vitamin naturally present in some foods, but the main source is synthesis within the body after exposure to sunlight. Vitamin D has various roles within the body, but primarily regulates the absorption of calcium in the gut, maintaining adequate serum calcium and phosphate concentrations that contribute to mineralization of bone.